- Email: [email protected]
Simulated Trauma and Resuscitation Team Training course—evolution of a multidisciplinary trauma crisis resource management simulation course
Accepted Manuscript Standardized Trauma And Resuscitation Team Training (S.T.A.R.T.T.) Course – Evolution Of A Multidisciplinary Trauma Crisis Resource Management Simulation Course Lawrence M. Gillman, MD MMedEd FRCSC FACS, Peter Brindley, MD FRCPC FRCP-Edin, John Damian Paton-Gay, MD FRCSC, Paul T. Engels, MD FRCSC FACS, Jason Park, MD MEd FRCSC FACS, Ashley Vergis, MD MMedEd FRCSC FACS, Sandy Widder, MD FRCSC MHA PII:
S0002-9610(15)00550-4
DOI:
10.1016/j.amjsurg.2015.07.024
Reference:
AJS 11692
To appear in:
The American Journal of Surgery
Received Date: 2 June 2015 Revised Date:
23 June 2015
Accepted Date: 19 July 2015
Please cite this article as: Gillman LM, Brindley P, Paton-Gay JD, Engels PT, Park J, Vergis A, Widder S, Standardized Trauma And Resuscitation Team Training (S.T.A.R.T.T.) Course – Evolution Of A Multidisciplinary Trauma Crisis Resource Management Simulation Course, The American Journal of Surgery (2015), doi: 10.1016/j.amjsurg.2015.07.024. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
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Abstract Background: We previously reported on a pilot trauma multidisciplinary crisis resource
Here we study the course’s evolution.
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course titled S.T.A.R.T.T. (Standardized Trauma and Resuscitative Team Training).
Methods: Satisfaction was evaluated by post-course survey. Trauma teams were
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Support (ATLS) primary survey checklist.
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evaluated using the Ottawa Global Rating Scale (GRS), and an Advanced Trauma Life
Results: Eleven "trauma teams", consisting of physicians, nurses and respiratory therapists, each completed 4 crisis simulations over 3 courses. Satisfaction remained high amongst participants with overall mean satisfaction being course 4.39 on a 5 point likert
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scale. As participants progressed through scenarios, improvements in GRS scores were seen between the 1st and 4th (29.8 vs 36.1 of 42, p=0.022), 2nd and 3rd (28.2 versus 34.6, p=0.017), and 2nd and 4th (28.2 versus 36.1, p=0.003) scenarios. There were no
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17.
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differences in ATLS checklist with mean scores for each scenario ranging 11.3-13.2 of
Conclusions: The evolved S.T.A.R.T.T. curriculum has maintained high participant satisfaction and is associated with improvement in team CRM skills over the duration of the course.
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Short Summary : The S.T.A.R.T.T. course is a multi-disciplinary, trauma team training course designed to teach crisis resource management (CRM) skills to trauma teams. The evolved S.T.A.R.T.T. curriculum has maintained high participant satisfaction and is
Keywords:
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associated with improvement in team CRM skills over the duration of the course.
Simulation, Trauma, Crisis Resource Management, Multi-disciplinary
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Education
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Standardized Trauma And Resuscitation Team Training (S.T.A.R.T.T.) Course – Evolution Of A Multidisciplinary Trauma Crisis Resource Management Simulation
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Course
Lawrence M Gillman MD MMedEd FRCSC FACS1 * ([email protected])
Peter Brindley MD FRCPC FRCP-Edin2 ([email protected])
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John Damian Paton-Gay MD FRCSC3 ([email protected]) Paul T. Engels MD FRCSC FACS4 ([email protected])
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Jason Park MD MEd FRCSC FACS1 ([email protected]) Ashley Vergis MD MMedEd FRCSC FACS1 ([email protected]) Sandy Widder MD FRCSC MHA3 ([email protected])
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Department of Surgery1, University of Manitoba, Winnipeg, Manitoba; Division of Critical Care Medicine2 and Department of Surgery3, University of Alberta, Edmonton, Alberta; Departments of Surgery and Critical Care Medicine4, McMaster University,
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Hamilton, Ontario.
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Conflicts of Interest and Source of Funding - None Declared. Presented as a podium presentation at the Trauma Association of Canada (TAC) Meeting in Calgary, Alberta, April 2015.
* Corresponding Author Z3053 – 409 Tache Avenue
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Winnipeg, Manitoba, Canada, R2H 2A6 Phone: (204) 258-1408 Fax: (204) 237-3429
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Email: [email protected]
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Introduction
Crisis resource management (CRM) training was first popularized and promoted
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by the aviation industry. These lessons have been adapted to other high-stakes industries as a means of reducing and mitigating human error. In medicine, CRM training programs have been developed in multiple specialties including emergency medicine (1), critical
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care(2), obstetrics/gynecology(3) and anesthesia(4-6). CRM training curricula often include team members from diverse surgical and medical specialties, and allied
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healthcare professions. However, many simulations use non-physician members in an ancillary role: as confederates who support physician education. True multidisciplinary training, where all team members are equal participants, and equal beneficiaries, is still rare.
We recently published pilot results from a national multidisciplinary trauma CRM
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course entitled S.T.A.R.T.T. (Standardized Trauma and Resuscitative Team Training)(7). This one-day training course was designed by a multidisciplinary team. It was delivered
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to Medical Doctors (MDs) (emergency physicians and surgeons), and two non-MD groups (respiratory therapists (RTs) and nurses (RNs)). The intent was to address the
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individual needs of each discipline and to promote training together as a unified team. This course has now been hosted 3 times at national meetings since the pilot. These meetings include the Canadian Surgery Forum and the national meeting of the Trauma Association of Canada. With each iteration of the course, modifications have been made to the course content, schedule and scenario design in response to participant and instructor feedback. The goal has been to improve the educational experience for all participants, regardless of specialty or profession. This manuscript summarizes data
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collected and lessons learned, in hopes that other health care professionals may create and
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participate in enhanced multidisciplinary learning environments.
Materials and Methods
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S.T.A.R.T.T. Course development
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The development of the initial curriculum has been previously published(7). At course conclusion, common debriefing sessions were held with all participants and instructors in an attempt to maintain the course’s strengths and identify areas for improvement. This was bolstered by written feedback (both narrative and Likert-scale) from participants
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immediately following each course. The course directors and curriculum committee met to review all feedback with the goal of ongoing improvement at the end of each course.
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The S.T.A.R.T.T. course(7) remains an eight-hour course introduced by two short lectures reviewing basic CRM principles and trauma-team roles and responsibilities.
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Participants are then oriented to the mannequins and equipment. Participants are divided into teams of 4-6 Attending or Resident Physicians (MDs), 1-3 RNs and 1-2 RTs. Teams then rotate through 4 standardized high-fidelity trauma simulations delivered using a simulation mannequin. Each simulation lasts approximately 15 minutes, immediately followed by a 45 minute debrief. All team members (MDs, RNs and RTs) are blind to the simulation scenario content and there are no confederates amongst the participants.
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Course Measures The courses were evaluated in three ways. First, as in the previous publication(7), all
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participants completed a post course satisfaction survey with all responses using a 5-point Likert scale (Appendix 1). Second, a single rater assessed the teams’ CRM skills as a group during each simulation session using the previously validated Ottawa Global
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Rating Scale (GRS)(2). The Ottawa GRS uses a 7- point Likert scale to assess
performance in 5 categories (leadership skills, problem solving skills, situational
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awareness skills, resource utilizations skills, and communication skills) and an overall performance score to yield a total maximum score of 42. Third, a separate rater assessed the teams’ adherence to standards of care defined by the Advanced Trauma Life Support
Statistical Analysis
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(ATLS) Course using a checklist developed for this study (Appendix 2).
Mean scores for each of the responses on the post course satisfaction survey were
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compared based on profession (MD, RT, RN) by one-way analysis of variance (ANOVA). Mean Ottawa GRS scores and ATLS checklist scores were compared for
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each simulation session using separate ANOVAs. All significant ANOVA differences (p < 0.05) were further analyzed by using post-hoc testing with Tukey’s HSD (honest significant difference) method to localize the pairwise differences.
Results
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Course modifications, based upon feedback In response to feedback, the following major modifications have been made to the course
1. Adoption of a team coach for each simulation team.
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curriculum since the original publication:
2. Addition of non-medical CRM based training activities to enhance communication and leadership.
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3. Development and utilization of specific strategies to enhance the experience of the multidisciplinary participants.
Post-Course Satisfaction Survey:
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Each modification is reviewed further in the discussion section of this paper.
Over four courses, a total of 68 MD’s (6 practicing physicians and 62 residents), 25 RN’s
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and 16 RT’s completed the course. Overall, mean satisfaction with the course was 4.39/5 (Standard Deviation (SD) 0.605). Mean satisfaction was 4.43/5 (SD 0.555) for MDs, 4.48 (SD 0.714) for RNs and 4.13 (SD 0.619) for RTs. There were no differences on one-way
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(Figure 1).
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ANOVA between responses to any of the satisfaction survey questions by profession
Ottawa GRS
A total of 11 groups each completed 4 scenarios. Mean GRS scores were compared for teams as they progressed through four scenarios. The mean GRS scores for the teams’ 1st through 4th scenarios were: 29.82 (SD 4.29), 28.18 (SD 5.40), 34.64 (SD 3.75) and 36.09 (SD 5.74) respectively from a possible maximum score of 42. As groups progressed
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through scenarios, significant improvements in scores were seen between their 1st and 3rd scenario, 2nd and 3rd, and 2nd and 4th (Figure 2).
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ATLS Checklist
Mean ATLS checklist scores for each group’s 1st through 4th scenarios were: 11.27 (SD 3.10), 13.18 (SD 2.60), 11.55 (SD 3.75) and 13.09 (SD 2.94) respectively, from a
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possible maximum score of 17. There were no differences between any of the scenario
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scores (data not shown).
Discussion
We previously reported results from the pilot of the multidisciplinary S.T.A.R.T.T. course(7). Despite high participant satisfaction across disciplines, the feedback
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highlighted the challenges in designing a multidisciplinary curriculum that both engages and challenges participants with diverse backgrounds and training. Three major changes were implemented:
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1) Adoption of a team coach
The original course had 4 “trauma teams” rotating between 4 simulation scenario
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stations. Each station also had 3 or 4 different instructors responsible for observing participant performance and facilitating the post-scenario debriefing session. Previously, instructors at one scenario were not aware of prior feedback that was given. Participant feedback suggested this design did not allow teams to build on their past performance because they commonly received similar feedback at each debrief. In response, we provided a “team coach” who followed a single team through all scenarios. Each “team
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coach” had extensive formal training in debriefing and CRM, and so could emphasize different points with each scenario and objectively assess whether teams were improving or regressing. This approach accentuated consistency and rapport between team members
the course progressed.
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2. Addition of non-medical CRM based training activities
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and the “team coach”. Teams could build on past performances and learn iteratively as
The majority of time was focused on trauma based high-fidelity simulations in the pilot
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course. We found that the introduction of brief (<30 minutes), lower fidelity, nonmedicine based training activities allowed for the introduction of important CRM skills that could then be applied during the scenarios. For example, we had the teams build the longest paper chain, or highest tower of blocks. Team members came from a variety of
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geographic centres and had not previously worked together, therefore these activities allowed an opportunity to practice CRM skills such as leadership and communication. This approach also facilitated team cohesion and rapport without the stress of
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concomitantly performing high-stakes simulated resuscitations.
3. Specific strategies to enhance the experience of both physician and non-physician participants.
In order to bolster a multidisciplinary learning environment where all participants have their individual learning needs addressed in a single scenario we: A. Created discipline specific objectives and tasks (8)
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With three professions (MD, RN, RT) requiring learning opportunities within a single scenario we found that the practice of defining individual, discipline specific objectives for each scenario led to greater participant satisfaction.
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B. Staged entry scenarios(8)
Given that the teams are relatively large, (total 9 to 11 participants) we had part of the team, the RN’s and RT’s, enter the simulation room first, followed by the remainder
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of the team (entry triggers can be time-based or clinical-event based). This allows for increased independence amongst the non-physician team members and creates
C. Remote resuscitation(8) –
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opportunities to practice handover and leadership-transition.
In 2008, Brindley et al.(9) described the benefits of a blindfolded simulation, in which the team leader is blindfolded thereby relying on the remainder of the team to
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verbalize all pertinent findings. They found the teams reported enhanced teamwork, role clarity, closed-loop communication, and bilateral communication amongst all team members. Our remote resuscitation scenario is a hybrid of the blindfolded simulation and
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the staged entry scenario discussed above. We set the scenario in a remote centre that is staffed by non-physicians (RNs and RTs) and resembles northern/remote nursing stations
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in Canada in an attempt to make the experience more realistic. Physician team-members are segregated in a separate room with a telephone and writing materials. Meanwhile, the non-physician team members are placed in the simulated resuscitation suite with a mannequin and participate in the physical simulation. The physicians can be reached by the RNs and RTs by phone and help direct the resuscitation over the phone without seeing the patient. These blended-scenarios were well received by participants.
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Satisfaction with the course was high amongst all participants with no differences by profession (Figure 1). This implies that our changes did not adversely affect the course
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and that we were successful in our goal of creating a curriculum that appeals to a multidisciplinary audience.
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Participating teams demonstrated measurable and progressive improvements in CRM skills (as reflected by the Ottawa GRS) as they advanced through the 4 scenarios.
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Recently, the Trauma Non-Technical Training (TNT)-2 course(10) demonstrated improvements in Ottawa GRS scores from the 1st to 2nd scenario but failed to show improvements on the 3rd scenario, which had the lowest score. Their work, and that of Yee et al(11), has hypothesized that the majority of observed improvement in non-
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technical skills occur between the first and second scenarios with little additional benefit thereafter. This may reflect increased familiarity with the simulation environment. Our results suggest otherwise. That is, we found no improvement in the second scenario but
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continued improvement with the third and fourth scenarios. Since this course was held at national meetings, the trauma teams were composed of participants who had not
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previously worked together. It may have taken the initial two scenarios to establish rapport and only after this could the teams focus on improving CRM skills. Another possibility is that the broad range of CRM skills discussed during the lecture sections and in debriefs were not incorporated effectively into practice until after 1 or 2 practice sessions. Of note, teams performed scenarios in a rotating order, with no two teams
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completing the scenarios in the same order. This should minimize the effect of scenario order or difficulty on our results.
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We also hypothesized that there should be an improvement in the ATLS checklist scores because improved CRM could translate into improved clinical performance. In addition, while the focus of the debriefing was on CRM rather than ATLS principles, discussion of
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factual knowledge is unavoidable during a comprehensive debriefing. Our data did not
demonstrate a difference between scenarios. Reasons include that our presumption that
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better CRM skills means better clinical performance may be flawed. Alternatively, the performance measure we used may be inadequate. The ATLS checklist was developed by the study personnel and has not been previously validated (in contrast to the Ottawa GRS score). In addition, the ATLS checklist only evaluated the steps of the primary survey and
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may not be sensitive or sophisticated enough to detect subtle differences in team clinical performance. A single performer is likely to have contributed significantly to each score in this area and thus the tool would not actually be assessing team function. If so then a
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better evaluation tool is needed.
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Our study has several limitations. First, none of the evaluators were blinded. Also, we had planned to use video and audio review of scenarios and multiple reviewers (blinded to the scenario number) for evaluation. However, due of the lack of video recording in a number of simulation centres this proved difficult. In the one centre where we had access to video recording, the audio quality was inadequate, meaning that scoring was problematic. Unlike the TNT-2 course (10) we did not examine learning-decay through
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delayed evaluations of each team. To date, we have only offered S.T.A.R.T.T. at national meetings (The Canadian Surgery Forum and the Trauma Association of Canada Meeting). This approach facilitates the involvement of instructors and participants from
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across Canada, and maximizes the potential for sharing and cross-pollination of ideas and practices. Delivering local courses will pose challenges that include ensuring
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reproducibility and maintaining the quality of instructors and debriefers.
The start up costs associated with high-fidelity simulation can be significant. That said,
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many centres already have much of the required infrastructure in place but there is variability across sites depending if they are owned and operated directly by the university or hospital, or by an outside entity. To date, our budget per course has varied from $3000 to $5000 (Canadian dollars) depending mostly on the cost of the simulation
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centre rental (range $1000 to $3500), however we also did not reimburse any instructors for their travel, accommodations or time commitment. Simulation equipment with lower physical fidelity is available at lower cost and easier portability (for instance a human
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volunteer combined with a tablet-based monitoring system (SimMon, Castle+Anderson
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ApS, Denmark)) but requires further study as to its effectiveness.
Conclusions
The S.T.A.R.T.T. course is a true multidisciplinary trauma CRM course that has excellent and equal satisfaction amongst all participating professions. Moreover, participants showed significant improvements in CRM skills as a team as they advanced through the course.
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References
Hicks CM, Kiss A, Bandiera GW, Denny CJ. Crisis Resources for Emergency
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1.
Workers (CREW II): results of a pilot study and simulation-based crisis resource management course for emergency medicine residents. CJEM. 2012
Kim J, Neilipovitz D, Cardinal P, Chiu M, Clinch J. A pilot study using high-
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2.
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Nov;14(6):354–62.
fidelity simulation to formally evaluate performance in the resuscitation of critically ill patients: The University of Ottawa Critical Care Medicine, HighFidelity Simulation, and Crisis Resource Management I Study. Crit Care Med.
3.
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2006 Aug;34(8):2167–74.
Haller G, Garnerin P, Morales M-A, Pfister R, Berner M, Irion O, et al. Effect of crew resource management training in a multidisciplinary obstetrical setting. Int J
Gaba DM. Crisis resource management and teamwork training in anaesthesia.
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4.
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Qual Health Care. 2008 Aug;20(4):254–63.
British journal of anaesthesia. 2010 Jun 15;105(1):3–6.
5.
Gaba DM, DeAnda A. A comprehensive anesthesia simulation environment: recreating the operating room for research and training. Anesthesiology. 1988 Sep;69(3):387–94.
6.
Gaba DM. Improving anesthesiologists' performance by simulating reality.
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Anesthesiology. 1992 Apr;76(4):491–4. 7.
Ziesmann MT, Widder S, Park J, Kortbeek JB, Brindley P, Hameed M, et al.
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S.T.A.R.T.T.: development of a national, multidisciplinary trauma crisis resource management curriculum-results from the pilot course. J Trauma Acute Care Surg. 2013 Nov;75(5):753–8.
Brindley PG, Paton-Gay JD, Gillman LM. Designing Multidisciplinary
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8.
Team Dynamics. Springer. 9.
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Simulations. In: Gillman LM, Widder S, Blaivas M, Karakitsos D, editors. Trauma
BRINDLEY P, HUDSON D, LORD J. The blindfolded learner—A simple intervention to improve crisis resource management skills☆. Journal of Critical
10.
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Care. 2008 Jun;23(2):253–4.
Doumouras AG, Keshet I, Nathens AB, Ahmed N, Hicks CM. Trauma NonTechnical Training (TNT-2): the development, piloting and multilevel assessment
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of a simulation-based, interprofessional curriculum for team-based trauma
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resuscitation. Can J Surg. 2014 Oct;57(5):354–5. 11.
Yee B, Naik VN, Joo HS, Savoldelli GL, Chung DY, Houston PL, et al. Nontechnical skills in anesthesia crisis management with repeated exposure to simulation-based education. Anesthesiology. 2005 Aug;103(2):241–8.
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Figure Legends Figure 1 – Mean responses based on a 5 point likert scale to items on the post-course satisfaction survey by profession (physicians or surgeons (MD), nurses (RN) and
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respiratory therapists (RT)). Error bars indicate standard deviation.
Figure 2 – Mean Ottawa global rating scale (GRS) score of a possible maximum score of
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42, for first through fourth scenarios. Error bars indicate standard deviation. * p = 0.022
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~ p = 0.017
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Appendix
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^ p = 0.003
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Appendix 1 - Post course satisfaction survey.
Appendix 2 – Advanced Trauma Life Support (ATLS) checklist.
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POST – COURSE SURVEY
Section I: Background/Experience
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1. Current Position: A. Emergency Nurse B. Ward Nurse C. Resident – PGY year ______ Program ________________________ D. Practicing physician - specify position/yr of practice ________________________ E. Instructor F. Respiratory Therapist
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2. Prior experience with simulation? (Choose one) A. None B. A little ( 1-5 simulations) C. Moderate (5 -10 simulations) D. Extensive (> 10 simulations)
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3. Prior resuscitation experience as part of a trauma team? (Choose one) A. None B. A little ( 1-5 simulations) C. Moderate (5 -10 simulations) D. Extensive (> 10 simulations)
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4. Have you taken an Advanced Trauma Life Support (ATLS) Course? A. Yes B. No
Section II. Course Evaluation 1. Please choose the box that best describes your agreement with the statement.
1.
Overall, how would you rate this course?
Poor
Fair
Good
Very Good
Excellent
1
2
3
4
5
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2. Please choose the box that best describes your agreement with the statement.
3. The educational format was conducive to learning. 4. The rooms and facilities were appropriate for the course. 5. The training was well organized.
8.
The training content (simulations, debriefing) was appropriate. The training prepared me to work effectively as part of a trauma team. The training was an effective use of my time.
9.
The training will help improve patient safety.
7.
10. I am confident that I can perform the task that I was trained in. 11. I am confident that I understood the training content.
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12. I am confident that I can apply the knowledge that I learned today. 13. As a result of this training, I feel more confident about my ability to work effectively in a team. 14. The training met my expectations.
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15. I would recommend this training to others.
Agree
Strongly Agree
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6.
Neutral
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2. The content was relevant to my educational needs.
Disagree
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1. The topics and content met the stated objectives.
Strongly Disagree
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5
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3. Please provide any comments about the course below:
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_________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________
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Airway assessed (foreign body removal, phonation, stridor, hoarseness,
subcutaneous emphysema)?
Patient in spinal precautions? NO
YES 3)
Interventions performed if airway compromise (chin lift, jaw thrust, oral airway, intubation) if impending problem? YES/ NO AIRWAY COMPROMISE
Assessment of breathing - respiratory distress and adequacy of ventilation? YES
5)
NO
If breathing compromised, was an intervention preformed (supplemental oxygen, needle decompression/ chest tube insertion)? YES/ NO BREATHING COMPROMISE
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NO
If evidence of circulatory compromise, was an intervention performed (tourniquet, compression, splinting, binder, suturing/ stapling)? YES/ NO CIRCULATORY COMPROMISE
9)
NO
Was adequate and timely IV access achieved (16 gauge or greater in < 5 minutes)? YES
8)
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YES 7)
NO
Circulation assessed (Vitals, evidence of external bleeding, end organ function (urine output, mental status)?
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6)
NO
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4)
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2)
NO
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YES
NO
Disability assessed (altered level of consciousness, lateralizing signs, pupillary changes)? YES
NO
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Was the patient adequately exposed while avoiding hypothermia? YES
12)
NO
Were a rectal exam and pelvic exam (when feasible) performed? NO
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YES 13)
Were primary adjuncts (Foley insertion, NG insertion, pulse oximetry, ECG) used appropriately? NO
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YES 14)
NO
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10)
Circle any of the primary adjuncts that were requested/ used: CXR
Lateral C-spine
FAST
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Pelvic X-ray
S0002-9610(15)00550-4
DOI:
10.1016/j.amjsurg.2015.07.024
Reference:
AJS 11692
To appear in:
The American Journal of Surgery
Received Date: 2 June 2015 Revised Date:
23 June 2015
Accepted Date: 19 July 2015
Please cite this article as: Gillman LM, Brindley P, Paton-Gay JD, Engels PT, Park J, Vergis A, Widder S, Standardized Trauma And Resuscitation Team Training (S.T.A.R.T.T.) Course – Evolution Of A Multidisciplinary Trauma Crisis Resource Management Simulation Course, The American Journal of Surgery (2015), doi: 10.1016/j.amjsurg.2015.07.024. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT
Abstract Background: We previously reported on a pilot trauma multidisciplinary crisis resource
Here we study the course’s evolution.
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course titled S.T.A.R.T.T. (Standardized Trauma and Resuscitative Team Training).
Methods: Satisfaction was evaluated by post-course survey. Trauma teams were
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Support (ATLS) primary survey checklist.
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evaluated using the Ottawa Global Rating Scale (GRS), and an Advanced Trauma Life
Results: Eleven "trauma teams", consisting of physicians, nurses and respiratory therapists, each completed 4 crisis simulations over 3 courses. Satisfaction remained high amongst participants with overall mean satisfaction being course 4.39 on a 5 point likert
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scale. As participants progressed through scenarios, improvements in GRS scores were seen between the 1st and 4th (29.8 vs 36.1 of 42, p=0.022), 2nd and 3rd (28.2 versus 34.6, p=0.017), and 2nd and 4th (28.2 versus 36.1, p=0.003) scenarios. There were no
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17.
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differences in ATLS checklist with mean scores for each scenario ranging 11.3-13.2 of
Conclusions: The evolved S.T.A.R.T.T. curriculum has maintained high participant satisfaction and is associated with improvement in team CRM skills over the duration of the course.
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Short Summary : The S.T.A.R.T.T. course is a multi-disciplinary, trauma team training course designed to teach crisis resource management (CRM) skills to trauma teams. The evolved S.T.A.R.T.T. curriculum has maintained high participant satisfaction and is
Keywords:
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associated with improvement in team CRM skills over the duration of the course.
Simulation, Trauma, Crisis Resource Management, Multi-disciplinary
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Education
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Standardized Trauma And Resuscitation Team Training (S.T.A.R.T.T.) Course – Evolution Of A Multidisciplinary Trauma Crisis Resource Management Simulation
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Course
Lawrence M Gillman MD MMedEd FRCSC FACS1 * ([email protected])
Peter Brindley MD FRCPC FRCP-Edin2 ([email protected])
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John Damian Paton-Gay MD FRCSC3 ([email protected]) Paul T. Engels MD FRCSC FACS4 ([email protected])
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Jason Park MD MEd FRCSC FACS1 ([email protected]) Ashley Vergis MD MMedEd FRCSC FACS1 ([email protected]) Sandy Widder MD FRCSC MHA3 ([email protected])
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Department of Surgery1, University of Manitoba, Winnipeg, Manitoba; Division of Critical Care Medicine2 and Department of Surgery3, University of Alberta, Edmonton, Alberta; Departments of Surgery and Critical Care Medicine4, McMaster University,
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Hamilton, Ontario.
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Conflicts of Interest and Source of Funding - None Declared. Presented as a podium presentation at the Trauma Association of Canada (TAC) Meeting in Calgary, Alberta, April 2015.
* Corresponding Author Z3053 – 409 Tache Avenue
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Winnipeg, Manitoba, Canada, R2H 2A6 Phone: (204) 258-1408 Fax: (204) 237-3429
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Email: [email protected]
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Introduction
Crisis resource management (CRM) training was first popularized and promoted
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by the aviation industry. These lessons have been adapted to other high-stakes industries as a means of reducing and mitigating human error. In medicine, CRM training programs have been developed in multiple specialties including emergency medicine (1), critical
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care(2), obstetrics/gynecology(3) and anesthesia(4-6). CRM training curricula often include team members from diverse surgical and medical specialties, and allied
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healthcare professions. However, many simulations use non-physician members in an ancillary role: as confederates who support physician education. True multidisciplinary training, where all team members are equal participants, and equal beneficiaries, is still rare.
We recently published pilot results from a national multidisciplinary trauma CRM
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course entitled S.T.A.R.T.T. (Standardized Trauma and Resuscitative Team Training)(7). This one-day training course was designed by a multidisciplinary team. It was delivered
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to Medical Doctors (MDs) (emergency physicians and surgeons), and two non-MD groups (respiratory therapists (RTs) and nurses (RNs)). The intent was to address the
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individual needs of each discipline and to promote training together as a unified team. This course has now been hosted 3 times at national meetings since the pilot. These meetings include the Canadian Surgery Forum and the national meeting of the Trauma Association of Canada. With each iteration of the course, modifications have been made to the course content, schedule and scenario design in response to participant and instructor feedback. The goal has been to improve the educational experience for all participants, regardless of specialty or profession. This manuscript summarizes data
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collected and lessons learned, in hopes that other health care professionals may create and
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participate in enhanced multidisciplinary learning environments.
Materials and Methods
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S.T.A.R.T.T. Course development
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The development of the initial curriculum has been previously published(7). At course conclusion, common debriefing sessions were held with all participants and instructors in an attempt to maintain the course’s strengths and identify areas for improvement. This was bolstered by written feedback (both narrative and Likert-scale) from participants
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immediately following each course. The course directors and curriculum committee met to review all feedback with the goal of ongoing improvement at the end of each course.
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The S.T.A.R.T.T. course(7) remains an eight-hour course introduced by two short lectures reviewing basic CRM principles and trauma-team roles and responsibilities.
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Participants are then oriented to the mannequins and equipment. Participants are divided into teams of 4-6 Attending or Resident Physicians (MDs), 1-3 RNs and 1-2 RTs. Teams then rotate through 4 standardized high-fidelity trauma simulations delivered using a simulation mannequin. Each simulation lasts approximately 15 minutes, immediately followed by a 45 minute debrief. All team members (MDs, RNs and RTs) are blind to the simulation scenario content and there are no confederates amongst the participants.
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Course Measures The courses were evaluated in three ways. First, as in the previous publication(7), all
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participants completed a post course satisfaction survey with all responses using a 5-point Likert scale (Appendix 1). Second, a single rater assessed the teams’ CRM skills as a group during each simulation session using the previously validated Ottawa Global
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Rating Scale (GRS)(2). The Ottawa GRS uses a 7- point Likert scale to assess
performance in 5 categories (leadership skills, problem solving skills, situational
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awareness skills, resource utilizations skills, and communication skills) and an overall performance score to yield a total maximum score of 42. Third, a separate rater assessed the teams’ adherence to standards of care defined by the Advanced Trauma Life Support
Statistical Analysis
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(ATLS) Course using a checklist developed for this study (Appendix 2).
Mean scores for each of the responses on the post course satisfaction survey were
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compared based on profession (MD, RT, RN) by one-way analysis of variance (ANOVA). Mean Ottawa GRS scores and ATLS checklist scores were compared for
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each simulation session using separate ANOVAs. All significant ANOVA differences (p < 0.05) were further analyzed by using post-hoc testing with Tukey’s HSD (honest significant difference) method to localize the pairwise differences.
Results
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Course modifications, based upon feedback In response to feedback, the following major modifications have been made to the course
1. Adoption of a team coach for each simulation team.
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curriculum since the original publication:
2. Addition of non-medical CRM based training activities to enhance communication and leadership.
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3. Development and utilization of specific strategies to enhance the experience of the multidisciplinary participants.
Post-Course Satisfaction Survey:
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Each modification is reviewed further in the discussion section of this paper.
Over four courses, a total of 68 MD’s (6 practicing physicians and 62 residents), 25 RN’s
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and 16 RT’s completed the course. Overall, mean satisfaction with the course was 4.39/5 (Standard Deviation (SD) 0.605). Mean satisfaction was 4.43/5 (SD 0.555) for MDs, 4.48 (SD 0.714) for RNs and 4.13 (SD 0.619) for RTs. There were no differences on one-way
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(Figure 1).
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ANOVA between responses to any of the satisfaction survey questions by profession
Ottawa GRS
A total of 11 groups each completed 4 scenarios. Mean GRS scores were compared for teams as they progressed through four scenarios. The mean GRS scores for the teams’ 1st through 4th scenarios were: 29.82 (SD 4.29), 28.18 (SD 5.40), 34.64 (SD 3.75) and 36.09 (SD 5.74) respectively from a possible maximum score of 42. As groups progressed
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through scenarios, significant improvements in scores were seen between their 1st and 3rd scenario, 2nd and 3rd, and 2nd and 4th (Figure 2).
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ATLS Checklist
Mean ATLS checklist scores for each group’s 1st through 4th scenarios were: 11.27 (SD 3.10), 13.18 (SD 2.60), 11.55 (SD 3.75) and 13.09 (SD 2.94) respectively, from a
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possible maximum score of 17. There were no differences between any of the scenario
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scores (data not shown).
Discussion
We previously reported results from the pilot of the multidisciplinary S.T.A.R.T.T. course(7). Despite high participant satisfaction across disciplines, the feedback
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highlighted the challenges in designing a multidisciplinary curriculum that both engages and challenges participants with diverse backgrounds and training. Three major changes were implemented:
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1) Adoption of a team coach
The original course had 4 “trauma teams” rotating between 4 simulation scenario
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stations. Each station also had 3 or 4 different instructors responsible for observing participant performance and facilitating the post-scenario debriefing session. Previously, instructors at one scenario were not aware of prior feedback that was given. Participant feedback suggested this design did not allow teams to build on their past performance because they commonly received similar feedback at each debrief. In response, we provided a “team coach” who followed a single team through all scenarios. Each “team
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coach” had extensive formal training in debriefing and CRM, and so could emphasize different points with each scenario and objectively assess whether teams were improving or regressing. This approach accentuated consistency and rapport between team members
the course progressed.
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2. Addition of non-medical CRM based training activities
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and the “team coach”. Teams could build on past performances and learn iteratively as
The majority of time was focused on trauma based high-fidelity simulations in the pilot
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course. We found that the introduction of brief (<30 minutes), lower fidelity, nonmedicine based training activities allowed for the introduction of important CRM skills that could then be applied during the scenarios. For example, we had the teams build the longest paper chain, or highest tower of blocks. Team members came from a variety of
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geographic centres and had not previously worked together, therefore these activities allowed an opportunity to practice CRM skills such as leadership and communication. This approach also facilitated team cohesion and rapport without the stress of
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concomitantly performing high-stakes simulated resuscitations.
3. Specific strategies to enhance the experience of both physician and non-physician participants.
In order to bolster a multidisciplinary learning environment where all participants have their individual learning needs addressed in a single scenario we: A. Created discipline specific objectives and tasks (8)
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With three professions (MD, RN, RT) requiring learning opportunities within a single scenario we found that the practice of defining individual, discipline specific objectives for each scenario led to greater participant satisfaction.
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B. Staged entry scenarios(8)
Given that the teams are relatively large, (total 9 to 11 participants) we had part of the team, the RN’s and RT’s, enter the simulation room first, followed by the remainder
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of the team (entry triggers can be time-based or clinical-event based). This allows for increased independence amongst the non-physician team members and creates
C. Remote resuscitation(8) –
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opportunities to practice handover and leadership-transition.
In 2008, Brindley et al.(9) described the benefits of a blindfolded simulation, in which the team leader is blindfolded thereby relying on the remainder of the team to
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verbalize all pertinent findings. They found the teams reported enhanced teamwork, role clarity, closed-loop communication, and bilateral communication amongst all team members. Our remote resuscitation scenario is a hybrid of the blindfolded simulation and
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the staged entry scenario discussed above. We set the scenario in a remote centre that is staffed by non-physicians (RNs and RTs) and resembles northern/remote nursing stations
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in Canada in an attempt to make the experience more realistic. Physician team-members are segregated in a separate room with a telephone and writing materials. Meanwhile, the non-physician team members are placed in the simulated resuscitation suite with a mannequin and participate in the physical simulation. The physicians can be reached by the RNs and RTs by phone and help direct the resuscitation over the phone without seeing the patient. These blended-scenarios were well received by participants.
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Satisfaction with the course was high amongst all participants with no differences by profession (Figure 1). This implies that our changes did not adversely affect the course
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and that we were successful in our goal of creating a curriculum that appeals to a multidisciplinary audience.
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Participating teams demonstrated measurable and progressive improvements in CRM skills (as reflected by the Ottawa GRS) as they advanced through the 4 scenarios.
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Recently, the Trauma Non-Technical Training (TNT)-2 course(10) demonstrated improvements in Ottawa GRS scores from the 1st to 2nd scenario but failed to show improvements on the 3rd scenario, which had the lowest score. Their work, and that of Yee et al(11), has hypothesized that the majority of observed improvement in non-
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technical skills occur between the first and second scenarios with little additional benefit thereafter. This may reflect increased familiarity with the simulation environment. Our results suggest otherwise. That is, we found no improvement in the second scenario but
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continued improvement with the third and fourth scenarios. Since this course was held at national meetings, the trauma teams were composed of participants who had not
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previously worked together. It may have taken the initial two scenarios to establish rapport and only after this could the teams focus on improving CRM skills. Another possibility is that the broad range of CRM skills discussed during the lecture sections and in debriefs were not incorporated effectively into practice until after 1 or 2 practice sessions. Of note, teams performed scenarios in a rotating order, with no two teams
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completing the scenarios in the same order. This should minimize the effect of scenario order or difficulty on our results.
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We also hypothesized that there should be an improvement in the ATLS checklist scores because improved CRM could translate into improved clinical performance. In addition, while the focus of the debriefing was on CRM rather than ATLS principles, discussion of
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factual knowledge is unavoidable during a comprehensive debriefing. Our data did not
demonstrate a difference between scenarios. Reasons include that our presumption that
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better CRM skills means better clinical performance may be flawed. Alternatively, the performance measure we used may be inadequate. The ATLS checklist was developed by the study personnel and has not been previously validated (in contrast to the Ottawa GRS score). In addition, the ATLS checklist only evaluated the steps of the primary survey and
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may not be sensitive or sophisticated enough to detect subtle differences in team clinical performance. A single performer is likely to have contributed significantly to each score in this area and thus the tool would not actually be assessing team function. If so then a
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better evaluation tool is needed.
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Our study has several limitations. First, none of the evaluators were blinded. Also, we had planned to use video and audio review of scenarios and multiple reviewers (blinded to the scenario number) for evaluation. However, due of the lack of video recording in a number of simulation centres this proved difficult. In the one centre where we had access to video recording, the audio quality was inadequate, meaning that scoring was problematic. Unlike the TNT-2 course (10) we did not examine learning-decay through
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delayed evaluations of each team. To date, we have only offered S.T.A.R.T.T. at national meetings (The Canadian Surgery Forum and the Trauma Association of Canada Meeting). This approach facilitates the involvement of instructors and participants from
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across Canada, and maximizes the potential for sharing and cross-pollination of ideas and practices. Delivering local courses will pose challenges that include ensuring
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reproducibility and maintaining the quality of instructors and debriefers.
The start up costs associated with high-fidelity simulation can be significant. That said,
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many centres already have much of the required infrastructure in place but there is variability across sites depending if they are owned and operated directly by the university or hospital, or by an outside entity. To date, our budget per course has varied from $3000 to $5000 (Canadian dollars) depending mostly on the cost of the simulation
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centre rental (range $1000 to $3500), however we also did not reimburse any instructors for their travel, accommodations or time commitment. Simulation equipment with lower physical fidelity is available at lower cost and easier portability (for instance a human
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volunteer combined with a tablet-based monitoring system (SimMon, Castle+Anderson
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ApS, Denmark)) but requires further study as to its effectiveness.
Conclusions
The S.T.A.R.T.T. course is a true multidisciplinary trauma CRM course that has excellent and equal satisfaction amongst all participating professions. Moreover, participants showed significant improvements in CRM skills as a team as they advanced through the course.
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References
Hicks CM, Kiss A, Bandiera GW, Denny CJ. Crisis Resources for Emergency
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1.
Workers (CREW II): results of a pilot study and simulation-based crisis resource management course for emergency medicine residents. CJEM. 2012
Kim J, Neilipovitz D, Cardinal P, Chiu M, Clinch J. A pilot study using high-
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2.
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Nov;14(6):354–62.
fidelity simulation to formally evaluate performance in the resuscitation of critically ill patients: The University of Ottawa Critical Care Medicine, HighFidelity Simulation, and Crisis Resource Management I Study. Crit Care Med.
3.
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2006 Aug;34(8):2167–74.
Haller G, Garnerin P, Morales M-A, Pfister R, Berner M, Irion O, et al. Effect of crew resource management training in a multidisciplinary obstetrical setting. Int J
Gaba DM. Crisis resource management and teamwork training in anaesthesia.
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4.
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Qual Health Care. 2008 Aug;20(4):254–63.
British journal of anaesthesia. 2010 Jun 15;105(1):3–6.
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Gaba DM, DeAnda A. A comprehensive anesthesia simulation environment: recreating the operating room for research and training. Anesthesiology. 1988 Sep;69(3):387–94.
6.
Gaba DM. Improving anesthesiologists' performance by simulating reality.
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Anesthesiology. 1992 Apr;76(4):491–4. 7.
Ziesmann MT, Widder S, Park J, Kortbeek JB, Brindley P, Hameed M, et al.
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S.T.A.R.T.T.: development of a national, multidisciplinary trauma crisis resource management curriculum-results from the pilot course. J Trauma Acute Care Surg. 2013 Nov;75(5):753–8.
Brindley PG, Paton-Gay JD, Gillman LM. Designing Multidisciplinary
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8.
Team Dynamics. Springer. 9.
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Simulations. In: Gillman LM, Widder S, Blaivas M, Karakitsos D, editors. Trauma
BRINDLEY P, HUDSON D, LORD J. The blindfolded learner—A simple intervention to improve crisis resource management skills☆. Journal of Critical
10.
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Care. 2008 Jun;23(2):253–4.
Doumouras AG, Keshet I, Nathens AB, Ahmed N, Hicks CM. Trauma NonTechnical Training (TNT-2): the development, piloting and multilevel assessment
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of a simulation-based, interprofessional curriculum for team-based trauma
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resuscitation. Can J Surg. 2014 Oct;57(5):354–5. 11.
Yee B, Naik VN, Joo HS, Savoldelli GL, Chung DY, Houston PL, et al. Nontechnical skills in anesthesia crisis management with repeated exposure to simulation-based education. Anesthesiology. 2005 Aug;103(2):241–8.
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Figure Legends Figure 1 – Mean responses based on a 5 point likert scale to items on the post-course satisfaction survey by profession (physicians or surgeons (MD), nurses (RN) and
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respiratory therapists (RT)). Error bars indicate standard deviation.
Figure 2 – Mean Ottawa global rating scale (GRS) score of a possible maximum score of
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42, for first through fourth scenarios. Error bars indicate standard deviation. * p = 0.022
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~ p = 0.017
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Appendix
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^ p = 0.003
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Appendix 1 - Post course satisfaction survey.
Appendix 2 – Advanced Trauma Life Support (ATLS) checklist.
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POST – COURSE SURVEY
Section I: Background/Experience
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1. Current Position: A. Emergency Nurse B. Ward Nurse C. Resident – PGY year ______ Program ________________________ D. Practicing physician - specify position/yr of practice ________________________ E. Instructor F. Respiratory Therapist
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2. Prior experience with simulation? (Choose one) A. None B. A little ( 1-5 simulations) C. Moderate (5 -10 simulations) D. Extensive (> 10 simulations)
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3. Prior resuscitation experience as part of a trauma team? (Choose one) A. None B. A little ( 1-5 simulations) C. Moderate (5 -10 simulations) D. Extensive (> 10 simulations)
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4. Have you taken an Advanced Trauma Life Support (ATLS) Course? A. Yes B. No
Section II. Course Evaluation 1. Please choose the box that best describes your agreement with the statement.
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Overall, how would you rate this course?
Poor
Fair
Good
Very Good
Excellent
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2. Please choose the box that best describes your agreement with the statement.
3. The educational format was conducive to learning. 4. The rooms and facilities were appropriate for the course. 5. The training was well organized.
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The training content (simulations, debriefing) was appropriate. The training prepared me to work effectively as part of a trauma team. The training was an effective use of my time.
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The training will help improve patient safety.
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10. I am confident that I can perform the task that I was trained in. 11. I am confident that I understood the training content.
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12. I am confident that I can apply the knowledge that I learned today. 13. As a result of this training, I feel more confident about my ability to work effectively in a team. 14. The training met my expectations.
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15. I would recommend this training to others.
Agree
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2. The content was relevant to my educational needs.
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3. Please provide any comments about the course below:
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Airway assessed (foreign body removal, phonation, stridor, hoarseness,
subcutaneous emphysema)?
Patient in spinal precautions? NO
YES 3)
Interventions performed if airway compromise (chin lift, jaw thrust, oral airway, intubation) if impending problem? YES/ NO AIRWAY COMPROMISE
Assessment of breathing - respiratory distress and adequacy of ventilation? YES
5)
NO
If breathing compromised, was an intervention preformed (supplemental oxygen, needle decompression/ chest tube insertion)? YES/ NO BREATHING COMPROMISE
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NO
If evidence of circulatory compromise, was an intervention performed (tourniquet, compression, splinting, binder, suturing/ stapling)? YES/ NO CIRCULATORY COMPROMISE
9)
NO
Was adequate and timely IV access achieved (16 gauge or greater in < 5 minutes)? YES
8)
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YES 7)
NO
Circulation assessed (Vitals, evidence of external bleeding, end organ function (urine output, mental status)?
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6)
NO
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4)
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2)
NO
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YES
NO
Disability assessed (altered level of consciousness, lateralizing signs, pupillary changes)? YES
NO
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Was the patient adequately exposed while avoiding hypothermia? YES
12)
NO
Were a rectal exam and pelvic exam (when feasible) performed? NO
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YES 13)
Were primary adjuncts (Foley insertion, NG insertion, pulse oximetry, ECG) used appropriately? NO
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YES 14)
NO
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10)
Circle any of the primary adjuncts that were requested/ used: CXR
Lateral C-spine
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Pelvic X-ray